The present invention relates, in general, to the noninvasive monitoring of low frequency heart rate and blood volume variability based on optical (visible and/or non-visible spectrum) signals and, in particular, to monitoring related parameters based on the processing of received optical signals. The invention can be readily implemented in connection with pulse oximetry instruments so as to expand the utility of such instruments.
Photoplethysmography relates to the use of optical signals transmitted through or reflected by a patient""s blood, e.g., arterial blood and/or perfused tissue, for monitoring a physiological parameter of the patient. Such monitoring is possible because the optical signal is modulated by interaction with the patient""s blood. That is, interaction with the patient""s blood, generally involving a wavelength and/or time dependent attenuation due to absorption, reflection and/or diffusion, imparts characteristics to the transmitted signal that can be analyzed to yield information regarding the physiological parameter of interest. Such monitoring of patients is highly desirable because it is noninvasive, typically yields substantially instantaneous and accurate results, and utilizes minimal medical resources, thereby proving to be cost effective.
A common type of photoplethysmographic instrument is the pulse oximeter. Pulse oximeters determine an oxygen saturation level of a patient""s blood, or related analyte values, based on transmission/absorption characteristics of light transmitted through or reflected from the patient""s tissue. In particular, pulse oximeters generally include a probe for attaching to a patient""s appendage such as a finger, earlobe or nasal septum. The probe is used to transmit pulsed optical signals of at least two wavelengths, typically red and infrared, through the patient""s appendage. The transmitted signals are received by a detector that provides an analog electrical output signal representative of the received optical signals. By processing the electrical signal and analyzing signal values for each of the wavelengths at different portions of a patient""s pulse cycle, information can be obtained regarding blood oxygen saturation.
The algorithms for determining blood oxygen saturation related values are normally implemented in a digital processing unit. Accordingly, one or more analog to digital (A/D) converters are generally interposed between the detector and the digital processing unit. Depending on the specific system architecture employed, a single multi-channel digital signal may be received by the digital processing unit or separate digital signals for each channel may be received. In the former case, the digital processing unit may be used to separate the received signal into separate channel components. Thus, in either case, the digital processing unit processes digital information representing each of the channels. Such information, whether in digital or another form, defines input photoplethysmographic signals or xe2x80x9cpleths.xe2x80x9d
These pleths generally contain two components. The first component is a low frequency or substantially invariant component in relation to the time increments considered for blood oxygen saturation calculations, sometimes termed the xe2x80x9cDC component,xe2x80x9d which generally corresponds to the attenuation related to the non-pulsatile volume of the perfused tissue and other matter that affects the transmitted plethysmographic signal. The second component, sometimes termed the xe2x80x9cAC component,xe2x80x9d generally corresponds to the change in attenuation due to the pulsation of the blood. In general, the AC component represents a varying waveform which corresponds in frequency to that of the heartbeat. In contrast, the DC component is a more steady baseline component, since the effective volume of the tissue under investigation varies little or at a low frequency if the variations caused by the pulsation of the heart are excluded from consideration.
Pulse oximeters typically provide as outputs blood oxygen saturation values and, sometimes, a heart rate and a graphical representation of a pulsatile waveform. The information for generating each of these outputs is generally obtained from the AC component of the pleth. In this regard, some pulse oximeters attempt to filter the DC component from the pleth, e.g., in order to provide a better digitized AC component waveform. Other pulse oximeters may measure and use the DC component, e.g., to normalize measured differential values obtained from the AC component or to provide measurements relevant to motion or other noise corrections. Generally, though, conventional pulse oximeters do not monitor variations in the DC component of a pleth or pleths to obtain physiological parameter information in addition to the outputs noted above.
The present invention is directed to using photoplethysmography to obtain physiological parameter information related to low frequency heart rate and blood volume variability. The invention thus provides important diagnostic or monitoring information noninvasively. Moreover, various aspects of the invention can be implemented using one or more channels and/or other components of a conventional pulse oximeter, thereby providing additional functionality to instruments that are widely available and trusted, as well as providing access to important information for treatment of patients on a cost-effective basis.
It has been recognized that low frequency heart rate and blood volume variability have important diagnostic significance and that such variability can be conveniently monitored through appropriate processing of pleth signals. In the latter regard, the pleth signal includes information regarding the patient""s pulsatile waveform and can be processed to provide information regarding waveform variations. Spectral analysis of heart frequency indicates that such spectra characteristically include three peaks: a peak associated with respiration that typically has a frequency around 0.3 to 0.5 Hz, but may have a frequency of 1 Hz or greater in the case of infants; a peak typically in the 0.1 Hz range associated with the autonomic nervous system or vaso motor center, sometimes termed the xe2x80x9cMayer Wavexe2x80x9d; and a very low frequency peak, e.g., less than 0.05 Hz, associated with temperature control. Regarding the second of these, the origin and nature of the Mayer Wave is not fully settled. For present purposes, the Mayer Wave relates to a low frequency variation in blood pressure, heart rate, and/or vaso constriction.
The Mayer Wave has particular significance for diagnostic and patient monitoring purposes. In particular, the amplitude and frequency of the Mayer Wave are seen to change in connection with hypertension, sudden cardiac death, ventricular tachycardia, coronary artery disease, myocardial infarction, heart failure, diabetes, and autonomic neuropathy and after heart transplantation. The present invention is based, in part, on the recognition that effects related to the Mayer Wave can be monitored based on analyzing a pleth to obtain physiological parameter information. In particular, it is expected that the Mayer Wave influences heart rate (and related parameters such as variations in blood pressure and blood volume) by direct influence on the vaso motor center. A pleth signal can be processed to monitor heart rate and variations therein, thus yielding diagnostic information related to the Mayer Wave. Alternatively or additionally, the pleth signal can be processed to monitor blood volume variations to obtain similar information related to the Mayer Wave.
A difficulty associated with obtaining physiological parameter information based on the Mayer Wave relates to distinguishing the effects associated with the Mayer Wave from effects associated with the above-noted respiration wave, particularly in view of the fact that each of these waves can occur within overlapping frequency ranges. There are a number of ways in which the Mayer Wave and the respiration wave can be distinguished, as described in detail in U.S. patent application Ser. No. 10/790,950, entitled xe2x80x9cMonitoring Physiological Parameters Based on Variations in a Photoplethysmographic Signalxe2x80x9d, filed concurrently herewith. It has been recognized that the spectral composition or frequency band of the Mayer Wave can be readily characterized and the Mayer Wave can conveniently be analyzed, for purposes of monitoring related blood volume and heart rate variations, by controlling or having the patient control his respiration rate to be outside of the Mayer Wave frequency band under analysis.
Thus, in accordance with one aspect of the present invention, a method is provided for monitoring a Mayer Wave effect, such as a low frequency variation in blood pressure, heart rate, blood volume and/or vasoconstriction. The method involves obtaining a pleth signal that is modulated based on interaction of a transmitted optical signal with a patient""s blood (e.g., arterial blood and/or perfused tissue), processing the pleth signal to identify an effect related to the Mayer Wave, and providing an output related to the Mayer Wave effect (e.g., a waveform, one or more values or other information, e.g., related to the amplitude and/or period/frequency of the Mayer Wave or variations therein). This method may be implemented in connection with a conventional pulse oximeter. In this regard, the step of obtaining a pleth signal may involve operating the pulse oximeter to transmit optical signals relative to the patient and provide a detector signal representative of the received optical signals and accessing at least a portion of the detector signal corresponding to one or more channels of the transmitted optical signals. For example, the oximeter may be operated to transmit single or multiple channel (e.g., red and infrared channels) signals. In either case, the detector signal will generally include a pleth signal. In the case of a multiple channel detector signal, each channel will generally include a pleth signal and information regarding one channel may be accessed in accordance with the present invention, or information regarding multiple channels may be used, e.g., by combining the channel signals.
Once the pleth is obtained, it may be processed in a variety of ways to identify a Mayer Wave effect of interest. In one implementation, such processing involves frequency based filtering to identify the effect of interest. In particular, a signal or series of values representing or otherwise based on the obtained pleth signal is filtered to selectively pass a spectral peak located between about 0.05 Hz and 0.5 Hz. The lower end of this range may be selected to eliminate at least a substantial portion of spectral power related to the very low frequency peak noted above associated with temperature control. The upper end of the noted range may be selected in conjunction with controlling the patient""s respiration rate. In this regard, 0.5 Hz will allow for separation of the Mayer Wave from the respiration wave for many applications. A filtering range of between about 0.08-0.2 may be preferred for isolation of the Mayer Wave from the noted, potentially interfering spectral peaks. More preferably, because the Mayer Wave is generally found within a narrow frequency band at about 0.1 Hz, a narrow band pass filter may be utilized having a nominal pass band width (designated in conventional fashion) of no more than about 0.05 Hz and including within such pass band (preferably substantially centered relative thereto) or the frequency 0.1 Hz. Such filtering generally enables identifying a Mayer Wave effect from the signal under analysis.
In accordance with another aspect of the present invention, a low frequency blood volume variation of a patient is monitored. The associated method involves obtaining a pleth signal (e.g., as described above), processing the pleth signal to obtain information regarding a low frequency blood volume variation of the patient, and monitoring the low frequency blood volume variation over time to identify a characteristic of interest for patient monitoring or diagnostic purposes. The low frequency blood volume variation generally relates to a spectral peak of the pleth signal located between about 0.05 Hz and 0.5 Hz. Thus, the obtained pleth signal may be band pass filter, as discussed above, to extract information regarding the noted blood variability. Because such low frequency blood volume variability is related to the Mayer Wave, changes in its amplitude and/or frequency may have diagnostic significance as noted above.
In accordance with a further aspect of the present invention, a low frequency heart rate variability of a patient is monitored. The associated method involves obtaining a pleth signal, analyzing the pleth signal to obtain heart rate information, analyzing the heart rate information to obtain information regarding heart rate variability information, and monitoring the heart rate variability information to identify a characteristic of interest. The resulting heart rate variability information may be monitored, for example, to identify Mayer Wave phenomena of potential diagnostic significance.
The step of obtaining a pleth signal generally involves receiving a digital signal representative of an optical signal modulated based on interaction with perfused tissue of a patient. Such a signal may be provided using components of a conventional pulse oximeter. Pulse oximeters typically transmit red and infrared signals, thereby yielding red and infrared pleths. Either or both of these pleths may be utilized in accordance with the present invention. In particular, each of these pleths generally has a fundamental frequency corresponding to the patient""s heart rate. Accordingly, either pleth can be used to yield the desired heart rate information. In general, for normally oxygenated patients, the infrared channel typically has the stronger pleth waveform and may be preferred for heart rate calculations. For poorly oxygenated patients, the red pleth may be preferred. In many cases, a combination of the two signals may provide a better waveform for heart rate analysis than either signal alone.
The pleth may be processed to obtain heart rate information in a variety of ways. As noted above, the pleth is generally a periodic signal having a fundamental frequency corresponding to the patient""s heart rate. Accordingly, heart rate may be determined by performing peak-to-peak measurements on the pleth to determine the pulse period and, hence, pulse frequency. For example, such maxima may be obtained by identifying a change in sign of differential values between successive samples or groups of samples along the pleth or of a function fitted to the pleth. Alternatively, other points on the waveform, such as nominal zero (or average pleth value) crossings may be monitored. Such zero crossings would be expected to have a frequency of twice the heart rate. Such period measurements can be complicated due to the typically noisy waveform of the pleths. Accordingly, multiple waveforms may be utilized.
Additionally, the heart rate calculations may be performed in the frequency domain. In this regard, a processor may be configured to obtain a Fourier transform of the pleth. Once the Fourier transform is obtained, the pulse rate can be identified as the fundamental frequency of the pleth corresponding to the patient""s heart rate. In any case, once the heart rate is determined, it can be monitored to identify low frequency variations of interest. In particular, oscillatory variations having a frequency associated with the Mayer Wave, as discussed above, may be monitored for diagnostic purposes.
One or more filters may be used in obtaining heart rate variability information based on a pleth signal in accordance with the present invention. In this regard, an adaptive filter may be used to track the fundamental frequency of the pleth and, hence, the patient""s pulse rate. For example, such a filter may function as a narrow band pass filter having a band pass that is centered on the fundamental frequency of the pleth. The transfer function of the filter may be varied, e.g., based on analysis of successive waveforms, to track the potentially changing fundamental frequency. The filter or associated logic may thus be adapted to output a time series of pulse rate values. Such a time series of pulse rate values, whether obtained as an output of an adaptive filter system or otherwise, may be filtered using an adaptive filter that tracks a selected spectral peak of the time series to provide an output related thereto. Such filtering provides a fast, robust and computationally efficient mechanism for noninvasively monitoring low frequency heart rate variability based on pleth signals.
According to a still further aspect of the present invention, a method is provided for monitoring a patient using a pleth instrument. The method involves configuring a pleth instrument relative to the patient for a pleth analysis, e.g., by attaching a probe to the patient, causing a respiration rate of the patient to be at least at a given threshold, operating the instrument to obtain a pleth signal, and operating the instrument to process the pleth signal to identify an effect related to the Mayer Wave and provide an output related thereto. As noted above, the Mayer Wave generally has a frequency of about 0.1 Hz. Accordingly, the threshold is preferably greater than 0.1 Hz, for example, at least about 0.167 Hz or 10 breaths a minute. In this regard, the patient""s respiration rate may be controlled, e.g., using a respirator, or the patient may be instructed to control his breathing. The pleth instrument may be operated to obtain a single or multi-channel pleth signal and one or more such channels may be processed to identify any suitable pleth effect such as low frequency variations in blood volume, pulse rate, blood pressure or vasoconstriction. Information relating to the effect of interest may be output as discussed above. Such use of a pleth instrument in conjunction with frequency controlled patient breathing allows for convenient monitoring of Mayer Wave effects.
An apparatus in accordance with the present invention includes an input port for receiving a pleth signal, a processor for processing the pleth signal to identify an effect related to the Mayer Wave and an output port for providing output information relating to the effect of interest. For example, the input port may be adapted for receiving a cable connected to a probe or may be a processor module configured to access a digital signal, and the output port may be a port configured to interface with an external monitor or other display device or may be a processor module configured to provide access to the output information in digital form. The processor preferably includes a filter for use in extracting information regarding the Mayer Wave effect directly from the pleth signal or from processed information obtained therefrom. For example, the pleth signal may be filtered to obtain low frequency blood volume variation information, or the pleth signal may be processed to provide heart rate information and this information may be filtered to yield low frequency heart rate variability information. The apparatus may be incorporated into a conventional pleth instrument such as a pulse oximeter. In this manner, the functionality of pulse oximeters may be advantageously extended.